~ Random essays on healthcare

A coworker of a friend was notified yesterday that a relative committed suicide. A young newlywed who had only been married four months. I don’t know any details, but while we talked about suicidal ideation, it dawned on me that there may be something we can do as individuals that in a small way may help. We need to be in-the-moment when we are talking with someone. How many times are we engaged in a conversation and are looking at our phone or watching the TV or otherwise distracted? In many cases, texting or Facebook posts like this have replaced real conversation – face-to-face looking each other in the eye conversations. Not only is that a matter of respect and manners it also consciously or subconsciously tells that individual that they are important. I know from personal experience that sometimes we dread talking to certain individuals. In my case, they are the ones who when you ask what time it is they tell you how to build a watch. Or it might be a significant other or a child who just wants to tell you about their day. You need to show that you care by putting your phone down, mute or turn off the TV, look them in the eye and give them your full attention. Be in-the-moment! It may seem like a small factor, but what you are communicating to them is that you care enough about them to pay attention. How many times have we heard family and friends of someone who committed suicide say there was no indication, he wasn’t depressed, he was in a good mood joking and smiling he never communicated to anyone that he was considering taking his life. It is not reasonable to approach every interaction with someone wondering if they are contemplating suicide. I cannot imagine starting off every conversation with, “are you planning to kill yourself?” But by being in the moment during a conversation, you are acknowledging that they are important to you and in a small way may communicate that someone is listening and they can trust you to listen. Once you implement this communication trait, I suspect that initially, conversations may be routine and not earth shattering or heartbreaking. But once they know that they can go to you and tell you anything without judgment, when those dark thoughts hit I would hope they will reach out to you in time to give them a big hug and let them know that they matter. This is just my thought for today, and I don’t intend to indict anyone who may be sitting there wondering could I have done anything differently. These are my thoughts for those who have not been personally touched by suicide, and maybe this minor lifestyle change might be the thumb in the dike that prevents a tragedy.

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“Attending the Pacific Coast Chapter meeting has allowed me the opportunity to meet local and regional exports in the field. I have built and maintained strong personal and professional relationships…

Last April, a Canadian woman named Stacey Yepes experienced stroke symptoms, but by the time she made it to the hospital her symptoms were gone. Because her physicians could not find any signs of stroke, they believed that she was displaying symptoms of stress and released her home. A few days later, she had a similar attack and used her phone to tape herself during an episode in which she suffered from facial drooping and slurred speech. The video helped her doctors diagnose her with TIA (transient ischemic attack).

In many cases of diseases with transitory symptoms, physicians are unable to diagnose patients and opportunities for early treatments are missed. In the case of TIA, it is especially important to establish an early diagnosis and provide treatment to prevent the progression of symptoms and permanent loss of brain tissue. TIA can lead to blood clotting in the brain, but early…

Is it a goal of your free-standing hyperbaric clinic to achieve UHMS Accreditation? If not, your facility is missing a huge opportunity. Having UHMS Accreditation sends the message to referring physicians, regulatory and insurance companies, patients, and your local community that meeting a national standard of high quality health care is your clinic’s #1 priority.

Becoming a UHMS Accredited facility proves that your facility has been examined at by a non-biased third party and found to be on a level playing field with a hospital environment. It also proves that your facility has a very competent clinical team. Accreditation reassures regulators and insurance companies by satisfying concerns about safety practices and quality patient care.

The Bottom Line

The bottom line is this, it may cost your facility more money up front to earn UHMS Accreditation, however, look at the cost benefit. If practitioners trust your facility and make more referrals…

The Safety Committee of the Undersea and Hyperbaric Medical Society recommends that a Safety Time Out/Pause (STOP) be performed prior to the start of every hyperbaric treatment. A STOP should be completed regardless of multiplace or monoplace operations. A STOP will be performed in order to be compliant with safety goals, to combat complacency, and document completion of our unique safety practices. We recommend that the STOP be modeled after the timeouts performed before surgical procedures.

The Practice of Hyperbaric medicine is a procedure-oriented specialty, each patient should have two identifiers verified and the patient should agree to the procedure. For the safety of patients and staff, we strongly encourage documentation of a STOP verifying the “Right Patient, Right Treatment and Right Safety.”

The STOP checklist should include:

Checking the patient ground (monoplace)

All prohibited items are removed from the chamber (both monoplace and multiplace)

As a veteran I was interested to hear what Obama had to say to the future leaders of one branch of the military. It was obvious from parts of his speech that he has clueless about the Warrior Ethos. Obviously, we do not want the military to be the first approach to solving world problems, however we know from experience that having that big hammer when it comes to driving a nail home is critical to maintaining our safety. By talking down to these new leaders of the Army, he basically told them they were not important. What he failed to recognize is that these are the leaders of the tip of the spear. His minimizing their importance was a travesty and dishonors all those veterans who have served. I realize I probably don’t have the big picture. After all the current President is smarter than all of us and knows what’s best for everybody based on his worldview. Mistakes have been made by previous administrations and with the acuity of hindsight they might have done things differently. He obviously wears rose-colored glasses when examining what his administration has accomplished, but there are too many examples of failed leadership on the part of him and his administration. This speech was another example of his lack of appreciation for the value of and sacrifices of our military. His legacy will be all talk and no action! Sign me, HMCS(FMF) US Navy Retired.

(OP-ED, May24, 2014) In 1996, while a graduate student in Ethics and Policy Studies I wrote the term paper below. This was approximately two years after ‘HilliaryCare” was declared DOA after two years of partisan bickering. One of the criticism of the Health Security Act of 1992 (HilliaryCare) was reduction of choice in physician and further intrusion by the feds in individual healthcare. So is Obamacare déjà vu all over again? I will leave the reader to their own conclusions, and in a future post I will expand on the importance of the fiduciary relationship between a healthcare provider and their patient and its effect on quality of care. RBG

When we discuss ethics in health care delivery, the conversation usually involves end of life decisions, informed consent, abortion, genetic engineering, confidentiality, patient autonomy, etc. These issues are the glamour issues of bioethics; the issues that evoke deep passions about the sanctity of human life or lack of sanctity. But there exists a more fundamental ethical problem with the delivery of health care and that is the relationship between the physician, the patient and the third party payer and the implied and explicit nature of each. What on the surface appears to be a three way relationship is in reality three distinct two-way relationships. The physician’s relationship with the third-party payer is a simple contractual relationship common to any business arrangement. The relationship between the patient and the third-party payer is also a contractual agreement, even though it is doubtful that the patient is a fully informed party to the contract.

The physician-patient relationship is unique because of the highly personal nature of the affiliation. The physician and the patient have a relationship that involves a significant amount of intimate trust. The physician is privy to personal information about you that is not commonly known. And you trust the physician to not only keep this information private, but to use it to further your best interests. This is the role of the physician as patient advocate that is inherent in the physician-patient relationship. Although you are ultimately responsible for your health, he/she is the shepherd that guides and counsels as you strive to maintain your health; the physician is the subject matter expert you have chosen to help you make your health care decisions. The physician’s expertise in diagnosing and treating illness are what you seek in this relationship. This very special fiduciary responsibility on the part of the physician is what makes the physician-patient relationship different from a business arrangement.

What I propose in this term paper, is that the uniqueness of the relationship between a physician and his patient cannot and must not be abridged by the contractual relationship between the physician and the third party payer.

First we will explore the extent of the unique relationship between the physician and the patient and the responsibilities of each party. Next we will look at what is happening to the health care delivery system, specifically with the advent of managed care and finally discuss the responsibilities and priorities of each party to the triad and their utility to society.

The Unique Relationship

Some might argue that the relationship between a physician and a patient is only slightly different than any other contractual arrangement. The slight difference is that it deals with a unique commodity; your health. However, this argument reduces the physician-patient relationship to a step above buying a car. Veatch, in his advocacy of a contractual model for medicine states,

“Here two individuals or groups are interacting in a way where there are obligations and expected benefits for both parties… The basic norms of freedom, dignity, truth telling, promise keeping, and justice are essential to a contractual relationship. The premise is trust and confidence even though it is recognized that there is not a full mutuality of interests. Social sanctions institutionalize and stand behind the relationship, …but for the most part the assumption is that there will be faithful fulfillment of the obligations. Only in the contractual model can there be a true sharing of ethical authority and responsibility.” (Veatch, 1988)

Dr. Veatch’s essay was published in 1972 and even though there is a certain attraction to defining the relationship between a physician and a patient with a contract, there are significant problems with that approach in the 1990’s. The primary purpose of a contract is to define the roles of the parties to the contract. This includes specifically identifying the benefits and burdens to each. While purchasing a house, a contract is certainly mandatory to protect both parties; and in purchasing a car you would certainly want a contract to spell out the protection you have in the event of problems with the purchase. For some of the same reasons the contract is essential in the above transactions, a contract is NOT appropriate for the physician-patient relationship. William F. May, responding to the “contractualists” states:

“…but it would be unfortunate if professional ethics were reduced to a commercial contract. First, the notion of contract suppresses the element of gift in human relationships. The contractualist approach to professional behavior falls into the opposite error of minimalism. It reduces everything to tit for tat. Do no more for your patients that what the contract calls for. Perform specified services for certain fees and no more… But it would be wrong to reduce professional obligation to the specifics of a contract alone.” (May, 1988)

A contract defines the relationship and a definition contains limits. The unique nature of the relationship between the physician and patient cannot be limited. The physician’s fiduciary responsibility cannot be superseded by a contract. His/her responsibility to the patient is to use his professional expertise, education and judgment to the best of his ability as an advocate for the patient. He brings to the relationship a significant amount of training, knowledge, experience, his own values and ethics and the ethics of his profession. His obligation is to use these to the benefit of the patient without limitation. Along comes “managed care”, which is a 1990’s solution to the high cost of health care. Managed care companies immediately recognized an opportunity to save money by providing financial disincentives to member physicians to limit the amount of health care they provide, thus placing the physician in a position to choose between his financial self-interest and his fiduciary responsibility to the patient.

Managed Care Organizations

With the advent of managed care organizations (MCO’s), health care has entered a revolution in the practice of medicine. Historically, the physician has decided how much of what kind of health care you would receive. With minimum interference from the third party payers, the physician would determine what tests to order, when you would be hospitalized, when you would be sent home from the hospital and what type of drugs you needed. These decisions were based on his professional judgement of what is best for you. With someone else paying the bills, you had little or no concerns about the costs of these decisions. With few limitations, the physician had carte blanche to act in your behalf. As health care costs increased, the people paying the bills began questioning decisions, limiting hospital stays, requiring preapproval for expensive procedures, and recommending the use of the cheaper generic drugs. In the 19901s, MCO’s have virtually shifted the decision making regarding your health from the physician to the insurance company. The MCO’s have developed “cookbooks” that direct which tests, drugs and procedures are approved for any given illness. Often, the physician’s request for approval for a treatment is reviewed by a clerk and compared to the “cookbook”. If it is not in the guidelines published by the insurer, it is more than likely denied. I personally experienced the arbitrary nature of this review process. In my job as a Hyperbaric Technician, we have to obtain preapproval from certain insurers prior to starting treatment. In one particular case, the treatment was denied as not indicated. When we requested a review by the insurer’s medical director, we were sent an article published in 1975 indicating that hyperbaric oxygen therapy was only effective in three specific cases. This response totally ignored the 20 years of research sent that study and the recommended indications of the national accrediting body for hyperbaric medicine.

Another problem that interferes with the physicians role as a patient advocate is what is referred to as the “gag clause”. The “gag clause” is a term that refers to the clause in numerous contracts between physicians and third party payers that prohibit the physician from discussing option s of treatments that are not covered by the insurer. If the physician determines that you require treatment X and that treatment is not covered by the insurer or the physician is unable to obtain preapproval to order it, he is prohibited in from even telling the patient about the treatment. In a Time article a physician quotes the following “gag clause” in his contract with a large HMO.

“Physicians shall agree not to take any action or make any communication which undermines or could undermine the confidence on enrollees, potential enrollees, their employers, their unions, or the public in U.S. Healthcare or the quality of U.S. Healthcare coverage.” (Gray, 1996).

This minimalistic approach to health care adversely affects the physicians ability to fulfill his fiduciary responsibility to the patient. This mechanism of medical decision making reduces every patient to a faceless entity. The patients lose the care custom tailored by the physician for the patient as a unique individual with unique needs.

Another concern is that the motives of the third party payer are not just to limit health care costs, but also to maximize the return on investment to the shareholders. Maximizing profit has always been a goal of businesses including insurance companies, but never have they been so militant about intruding on the relationship of physician and patient and subordinating the well-being of the patient to the profit of the shareholder. The CEO’s of these companies are paid some of the highest salaries and bonuses in corporate America contingent on maximizing profits. A recent San Francisco Examiner article stated “Some of the profits turn up as multimillion-dollar salaries for HMO executives like Foundation Health Corp. Chairman Daniel D. Crowly, whose salary and bonus in 1994 was $3.3 million. On February 19, 1996 on The Phil Donahue Show, a physician appeared and stated that the CEO of the HMO he worked for was paid $20 million last year and owned 500 million dollars’ worth of stock in the HMO. (Krieger, 1996).

Some would argue that the sole function of a business is to maximize the return to the shareholder. Milton Friedman in 1962 wrote:

“The view has been gaining widespread acceptance that corporate officials and labor leaders have a ‘social responsibility’ that goes beyond serving the interest of their stockholders or their members. This view shows a fundamental misconception of the character and nature of a free economy. In such an economy, there is one and only one social responsibility for business-to use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game, which is to say, engages in open and free competition, without deception or fraud.” (Friedman, 1988).

In fairness to Mr. Friedman, this problem did not exist in 1962 when he wrote this quote. However, it does illustrate a problem with the privatization of health care. Corporate America has always argued that the market economy is self-regulating and that with modern management techniques, they can operate more efficiently than a government run entity. The question arises when the savings realized by operating more efficiently is diverted into investor’s accounts rather than in a reduction of premiums or an expansion of coverage. According to one article, the California Medical Association asserts that “The six largest
HMOs in California in 1994 earned profits of more than $1.3 billion and accumulated cash reserves of $5.6 billion…” (Krieger, 1996) I believe that a free market applies to most businesses and is the basis of our economy. However, when profit maximization takes precedence over patient well-being, we are dealing with a unique business that requires a higher standard of community responsibility.

Discussion

The physician-patient relationship has always been at the core of health care. It can work successfully only if there is a level of trust that the physician will advocate what is best for the patient. Profit making is not an issue unless it interferes with the relationship between the patient and physician. The altruistic element of the relationship will be strained when the third party payer punishes the physician financially for ordering too many tests, procedures or hospital days. A recent article in the Las Vegas Review Journal states “Doctors demoralized by managed care plans are hanging up their stethoscopes in frustration over red tape and loss of control.” The article goes on to say: “…membership surveys by the AMA and other groups over the past five years have revealed growing frustration as more companies adopt managed care programs that promise comprehensive health care benefits for flat fee. The plans generally work by restricting access to doctors, hospitals and medications and closely scrutinizing treatments.” (Associated Press, 1996). A group called the Consumers & Nurses for Patient Protection, formed in California by the California Nurses Association and Ralph Nader et al, is circulating a petition to qualify “The Patient Protection Act of 1996” (PPA) for the ballot in California in the fall. The PPA includes provisions that prohibit an insurer from paying a physician to limit care. It also prohibits an insurer from retaliating against a health care provider who advocates for the patient and it prohibits an insurer from denying treatment recommended by the patients physician unless that denial is by an appropriately qualified health professional, who has physically examined the patient. (Krieger, 1996) All of these provisions will help maintain the physician-patient relationship. It allows the physician to use his best clinical judgement to benefit the patient without worrying about making payroll to pay his office staff.
It is important to recognize that both the physician and the patient must also be cognizant of their responsibility to society. Although the physician-patient relationship must be one of trust, it does not exist in a vacuum. Health care is a limited resource and the physician has a responsibility to society to use that resource wisely. The patient also has an obligation as a member of the polis to minimize his/her need for health care by maintaining a healthy lifestyle, ie. Not smoking, wearing your seatbelt, refraining from high risk sex, avoiding the use of emergency departments for routine care, wearing a helmet while riding a motorcycle and the list goes on. William May sums it up this way;

“The professional covenant concerning health should be situated within a larger set of covenant obligations that both the doctor and patient have to other institutions and priorities within society at large. The traditional models for doctor-patient relationship (parent, friend) tend to establish an exclusivity of relationship that obscures these larger responsibilities. At a time when health needs command $120 billion out of the national budget, one must think about the place that the obligation to the limited human good of health has among a whole range of social and personal goods for which men are compacted together as a society. . .” (May, 1988).

Conclusion

With the current trend of third party payers dictating the amount of health care one receives, their motives might not be in your best interests or even in the best interest of the fellow members of your “risk pool”. The third party payer’s primary goal might be to maximize return on investment for the owners. Their contract with your physician will reflect their primary goal, forcing him/her to sacrifice what is best for you in order to stay in business. It is imperative that the sanctity of the physician-patient relationship be maintain in order to maintain the integrity of the health care system. It is entirely appropriate for insurers to monitor the actions of physicians who they have contracted with and make recommendations regarding their practice patterns. However, it is unethical for the insurer to interfere in the relationship between the patient and the physician by offering financial incentives to provide a less than appropriate level of health care.

This paper will address some of the challenges and opportunities in medical tourism. The medical tourism industry is still evolving and there is limited experience data with which to make truly informed choices. Several of the authors presented have developed decision matrices for consumers of medical tourism to assist with the decision process; however the decision for a medical provider to cater to medical tourist is a little less certain. A couple of local (Las Vegas) physicians who cater to medical tourism are used to illustrate micro models of a form of medical tourism that is feasible.

Globalization of Health Care – Threat or Opportunity

The globalization of healthcare is expanding at an ever-increasing rate. Chilingerian, McAuliffe, and Kimberly (2012) states “… that the world of healthcare is globalizing (or becoming flatter), but that we are really only at the beginning stages of this process, a process that is likely to accelerate with the passage of time.” (p. 433). This new and challenging healthcare landscape change represents several strategic options of the US healthcare system. One of the primary traits of this globalization is patients traveling not only regionally but across international borders to seek and receive healthcare. The ease of international travel and the ability of patients to search via the Internet for facilities and healthcare providers that are the best according to international healthcare rating indexes at what they do. If you require a relatively common surgery but particularly if you require a sensitive relatively rare surgery, you quite naturally within the limitations of your financial situation want to seek the best care possible at the best value. An industry that has sprung up in response to the demand is travel agencies and professional organizations that cater to the medical tourist. One example is the Medical Tourism Association that caters to companies that provide services to individuals seeking to travel for whatever reason for healthcare. (Stephano, 2012). Self-promoted as a vehicle to promote safe medical tourism they appear on their website to respond more to advertiser dollars than patient’s best interests. These travel intermediaries act as a broker between the consumer and provider of medical tourism options can provide travel and lodging at a reduced rate. (Altin, Singal, & Kara, n.d.).

For medical tourists from the US, value is a major factor second possibly only to quality. Chilingerian et al. (2012) cites one study that demonstrated a 90% cost savings for a procedure in the United States versus the same procedure at an international accredited destination. Joint Commission International (JCI) created in 1994 accredits healthcare facilities internationally and is a subsidiary of The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) in the US, which is the premier organization in the US for accrediting healthcare organizations. (JCI, 2012). This presents the medical traveler with a high degree of reassurance as to quality and safety at a non-US facility. Since being established the JCI as accredited approximately 150 international hospitals to standards similar to those used to accredit US hospitals.(Chilingerian et al., 2012, p. 436). Dr. Dominic Ricciardi, an internal medicine physician and a personal friend, specializes in medical weight loss and provides follow-up care for patients who received lap band surgery in Mexico. He has contracts with several insurance companies in Southern Nevada to provide the follow-up care. Based on his eight years’ experience, the complication rate of lap band procedure performed in selected facilities in Mexico is approximately 10% which is comparable to the complication rate of lap band surgeries done in the US. (Ricciardi, 2012). One of the minor risks of travel outside your home country is exposure to new bacteria that your body has not developed antibodies to combat. Hill (2011) discusses the risk of spreading an antibiotic resistant bacteria from one country to another via a medical tourism. Dr. Hill notes that the United Kingdom has one of the highest methicillin-resistant staph aureus (MRSA) rates in Europe. Two factors that contribute to the spread of antibiotic resistant bacteria include under or over use of antibiotics and lack of appropriate follow-up after a surgical procedure. In many countries such as Mexico, antibiotics are available over-the-counter which could lead to their misuse. There are many physicians such as Dr. Ricciardi who provide postsurgical follow-up for patients who receive their lap band surgery across borders. None of the literature reviewed quantified failure to follow up. Unless the out of country facility as an agreement with a resident country provider for follow-up there is no effective means of tracking that variable until an individual presents with a postop infection or other complication. Hill (2011) cited a study regarding the spread of a new antibiotic resistant bacteria called NDM-1. It is considered particularly dangerous because even the antibiotics that are used as a last resort have no effect. The study noted that several of the British cases of NDM – 1 recently had surgical procedures in India, Pakistan or Bangladesh. (p. 287). Anecdotally, a well-respected plastic surgeon in Las Vegas Nevada operates, in addition to his large local practice, a large accredited plastic surgery facility in Mexico where he offers packaged cosmetic procedures at half the cost of the same procedure in the US including transportation, visas, room and board, etc. As part of the package price he then provides follow-up back in Las Vegas for his medical tourists. In addition, some third-party payers have determined that cost savings are worth a pilot program to send patients to India, Mexico, and Thailand for treatments. And they include in their packages a referral to a state side provider for followup and management on any complications. When third party payers start contracting with out of country providers, it has significant potential impact on stateside facilities and physicians who are not flexible when it comes to price negotiations with insurance companies.(Chilingerian et al., 2012).

A study by Ehrbeck, Guevara and Mango cited by Chilingerian et al. (2012) found five reasons for international travel for acute-care medical treatment. They include better quality; the most advanced technology; quick access; lower cost for medically necessary procedures; and lower costs for discretionary procedures. (p. 436). It is interesting to note that lower-cost was the least common reason for seeking international medical care and better quality was the most common reason. This may be presumed to be counter to our natural ethnocentrism however with the increasing multiculturalism in the US; it appears to be less and less of an issue. An analysis of patient flows from North America shows that approximately 45% of the outbound patients go to Asia for care. Another 26% go to Latin America for care and within North America, Canada and the US, 27% of patients make that trip. (Chilingerian et al., 2012, p. 437).

According to Chilingerian et al. (2012) there are five categories of medical tourists. The first group is wealthy patients from countries with a high GDP that lack comprehensive health service. Examples cited include Qater, Bahrain, and United Arab Emirates. One measure of the degree of local healthcare infrastructure is infant deaths per 1000 live births. All three of the above cited countries have a relatively high in for mortality rate. The second category is medical tourists from countries with a large disparity between rich and poor. This would include countries like Turkmenistan, Jordan, Malaysia, Vietnam, the Philippines, Pakistan, Indonesia, India and China. These countries do not have a significant middle class and as such they lack significant comprehensive health service and experience a relatively high infant mortality rate. Another category is patients from countries with a relatively high GDP and relatively expensive healthcare services. Japan and the United States are excellent examples of this category. One example provided is an American patient who can fly to India and have a coronary artery bypass graft for 10% of the cost of having it done in the US. This is a significant benefit to patients with no health insurance assuming equivalent quality. The fourth category of patients is those from countries with historically long waits. This occurs primarily in countries with government-sponsored national health systems, where funding is reduced or limited. These lengthy waits can be both physiologically and psychologically difficult for patients. One study cited indicated urgent cases can wait as long as 30 months and non-urgent cases can wait as much as 78 months. In Canada the weight may be as much as three years for a hip and/or knee replacement. Patients willing to travel rather than tolerate pain and discomfort for months and years indicated that not only do they save money but the value added is less time in pain. The fifth category is a select group of patients that not only are seeking better outcomes but five-star service from the facility. Although most destinations for medical tourist state that only about 10% of their clients come from abroad there are certain hospitals that specialize in medical tourists. One facility in Bangkok Thailand treats 400,000 international patients from 154 countries providing five-star hotel services which includes “…deluxe rooms, VIP and Royal suites, laptop computers, a swimming pool, and a fitness center, and is within walking distance of Bangkok’s most prestigious restaurants, shopping, and entertainment venues.” (p. 439). In Canada, where the health delivery system is a mixture of national health system and private enterprise, there are facilities that derive over half their income from Americans traveling across the borders to receive high-quality specialized care at a reduced rate.

Lunt et al. (2011) in their report categorized patients into subsets: temporary visitors abroad and long-term residents. Temporary visitors are those who travel specifically across borders to receive medical care or plan a holiday across borders and receive medical care as a result of an accident or sudden illness. Long-term residents are those who retire or choose to reside in a country other than their country of origin and receive health services in their country of residence. Arguably, the long-term residents may not be considered a category of medical tourists. (p. 8).

Keckley and Underwood (2008) utilized a much less specific way of categorizing medical tourists. They grouped them into outbound, inbound and intra-bound or domestic medical tourists. The data for the domestic medical tourists was insufficient to accurately assess potential in the market, so the report focuses on outbound and inbound international medical tourists. They state that in 2007 an estimated 750,000 Americans traveled abroad for medical care. They projected that the number seeking care outside of the US will increase to 6 million by 2010 tempered by factors such as ability of foreign countries to supply the healthcare, US health plans denying coverage for care provided outside the US borders, US providers increase competition for these patients, and government policies that may restrict demand.(p. 3). In 2009 Keckley and Underwood (2009) updated their previous report maintaining the same three categories while addressing some of the previous factors that might affect the expansion of medical tourism. They cited three large insurers that have established a medical tourism pilot program and to state programs to incentivize medical tourism. All of these in the name of reducing cost to the consumer.(pp. 3-4).

International inbound medical tourists represent a source of revenue, often cash, to facilities who have both the reputation as a center of excellence in a specific product line and who make the effort to market to those groups of patients. As stated by Chilingerian et al. (2012) however, facilities who develop the infrastructure to cater to this rather select group of patients faces the risks and uncertainties generated by a potentially unstable environment. As other countries see patients leaving to go overseas and adapt their health services to better serve the needs of their citizens the demand for services in the US may drop. A hospital that has invested significant capital in facilities and equipment to specifically handle a significant number of medical tourists may have to realign their strategic plan if their volume of patients does not meet expectations. As stated by Lunt et al. (2011), “The demand for services may also be volatile with travel determined by both wider economic and external factors, as well as shifting consumer preferences and exchange rate.” (p. 13). Certain questions remain about the effects of supply and demand on the movement of patients across borders. Some could argue that as economic conditions deteriorate a patient who planned an elective procedure in their country of residence may make the trip across borders to receive the procedure at an overall reduced cost as opposed to forgoing the procedure altogether. According to Baran (2011), health care prices in the US has fueled the growth of international medical tourism. Heart bypass surgery that cost $100,000 in the US compared to 10 to 20,000 in countries such as India, Thailand and Singapore. The downturn in the economy beginning in 2008 negatively impacted medical tourism with the estimated number of tourists falling from 750,000 in 2007 two 540,000 in 2008 outbound from the US. However, due to the significant savings and increasing reassurance of equivalent quality the professional medical tourism groups project a 35% annual growth in medical tourism. Josef Woodman, author of “Patients Beyond Borders”, believes that the numbers cited are inflated and are more likely to be in the 400,000 patient range. (p. 2).

Obviously less expensive is a motivating factor for individuals who cannot or will not pay for elective procedures based on price alone. As reassurance is provided regarding the equivalent quality through accreditation organizations, the medical tourist will have to overcome the natural tendency to think that cheaper implies a lower quality. For example, Bangkok Thailand has six medical facilities that have hospital accreditation from the US. (Hutchinson, 2005). Accreditation by a subsidiary of the same organization that accredits all of the United States acute-care facilities is a significant endorsement of quality care. Smith and Forgione (2007) attributes the cost differences to lower labor costs, little to no malpractice costs, and lower pharmaceutical costs. She cites a report of the Centers for Medicare and Medicaid Services that 70% of healthcare costs are labor related. (p. 25). Altin et al. (n.d.) states, “This demand – supply gap has resulted in a lucrative business development opportunity for several countries like India, Thailand, Singapore, Turkey, Dubai and others where labor, both skilled and unskilled, and infrastructural facilities costs are considerably lower.” (p. 2). Smith and Forgione (2007) cites cost as the number one reason for Americans traveling overseas for healthcare. However, Runnels and Carrera (2012) state, “… the direction of movement is not one way and that wide price differentials alone, while instrumental in the calculus for seeking care abroad, do not drive medical tourism.”(p. 2). They conclude that the primary drive of growth in the medical tourism trade is unmet individual needs for healthcare. One of the causes of the unmet need may be cost; however unlike shopping for clothes, we probably will not purchase health care just because it is on sale.

As stated earlier labor costs are significant driver of overall health costs. A central point of the current election process and our economic problems is the transfer of jobs overseas where there are significantly lower labor costs which reduced costs to the consumer. This applies to health service delivery also. Chilingerian et al. (2012) discusses the flow of healthcare workers across borders. The ability of high income countries to offer increased wages and benefit packages to skilled workers has created a maldistribution in some of the poorer countries. Graduates in one country are not necessarily going to stay in that country to practice. This creates a worker flow of the pay scale which often means moving to a more developed country. Africa appears to be at the bottom of the barrel so to speak. According to Chilingerian et al. (2012), “Africa carries 25% of the world’s disease burden, yet has only 1.3% of the world’s health workers.” It is also estimated that about 1/5 of the African born physicians and 1/10 of the African born professional nurses are working overseas in higher income countries. (pp. 441-442). Often the healthcare professionals that tend to immigrate are experienced and/or highly skilled. This also creates diminished healthcare services quality in that the new healthcare workers lack senior supervision to further their education and increase their skills. There are also significant financial implications to this brain drain. For example one organization estimates that the United States has saved $3.86 billion as a consequence of importing 21,000 doctors just from Nigeria. (p. 443). However this brain drain also costs the country that trained the physician in not only loss of their services but cost of their education. Some of this loss is offset by what is referred to as migrant remittances. Migrant professionals are in a position to send significant amount of financial support to their family in the country of origin. The report cited gave three factors to explain this trend:

Remittance flows are now the second largest source of external funding for development countries (foreign direct investment being the largest)

Remittances are one of the least volatile sources of foreign exchange for developing countries

This phenomenon does not apply to just healthcare professionals. Migrant farm workers in the US who receive what most would Americans would consider very low pay are able to send part of their pay to family in Mexico, which provides the majority of support for those family members.(Anonymous, 2012).

The scale of health worker migration has created a movement towards manage migration which would link state and federal health policy goals in such a way as to control health workers immigrating. This would benefit both source and destination country. The ethical issues of rich countries poaching healthcare workers from developing countries and countries with a medically underserved population have yet to be agreed upon.(Chilingerian et al., 2012, pp. 444-445).

The overall implication is that the global supply of healthcare workers is insufficient to meet the healthcare needs of the world population. There does not appear to be effective ways of dealing with the maldistribution until an adequate supply of skilled healthcare workers are available.

The implications for the grassroots healthcare manager are significant, however the solutions might be considered above the pay grade of even the CEO of any given facility. A large facility might as part of their planning strategy put into motion a plan to become a center of excellence and market that capability overseas, either directly or through one of the many medical tourism organizations. It is much more likely that the myriad of problems and challenges associated with this undertaking should be handled by large healthcare conglomerate that includes acute-care facilities, long-term care facilities, an associated medical practice group, and a memorandum of understanding with one or more health insurer that will support this type of endeavor.

Hill, Tamra L. (2011). The Spread of Antibiotic-Resistant Bacteria Through Medical Tourism and Transmission Pevention Under the International Health Regulations. Chicago Journal of International Law, 12(1), 273-308.

R.B. Gustavson, MPH, RN
Abstract
The adverse health effects of cigarette smoking are well established and well publicized. Less well known and accepted are the adverse health effects of environmental tobacco smoke. Environmental tobacco smoke includes exhaled mainstream smoke, sidestream smoke coming off the burning tobacco and a newly labeled element called thirdhand smoke. Thirdhand smoke is the residue left on surfaces after secondhand smoke has dispersed. This residue contains the same toxins and carcinogenic material that mainstream smoke contains but often in more concentrated quantities. The members of society that are most susceptible to the deleterious effects of thirdhand smoke are children, pregnant women and non-smoking roommates of smokers. The residue clings to surfaces such as furniture, carpets, curtains and clothes. Thus the child crawling on the carpeted floor, playing on the couch, snuggling up with dad even when he’s not smoking and the stay-at-home mom exposed most of the day to thirdhand smoke in the home are the victims of this unintentional but nonetheless hazardous environmental exposure. This paper argues that there is a need for additional research in this area and immediate need for education of smokers and caregivers as to the hazards involved.

Introduction
The deleterious effects of smoking are well documented (Center for Disease Control and Prevention, 2011a, 2011b; Mokdad, Marks, Stroup, & Gerberding, 2004). Less well documented and slightly less accepted by the smoking public are the deleterious effects of secondhand smoke (Office of the Surgeon General, 2006). Several tobacco industry sponsored blogs dispute the Surgeon General’s claims of deleterious health effects from secondhand smoke however these are opinion pieces with no data to support their conclusions (Simpson, 2010; Tortorici, 2010). In addition, there is another category of smoke recently labeled as third-hand smoke (THS). Secondhand and third-hand smoke may be grouped together as environmental tobacco smoke. Secondhand smoke consists of smoke exhaled by the smoker and what is referred to as side stream smoke which is the smoke coming off the cigarette as the tobacco burns. Third-hand smoke is the residue left on surfaces in the environment after the secondhand smoke dissipates. This paper proposes that third-hand smoke is an underestimated cause of health problems, both mental and physical, in infants and children. Rehan, et al. (2011) state, “Currently, there is virtually no realization that THS is a danger to human health. A recent study by Winickoff et al. showed that only 65.2% of non-smokers and 43.2% of smokers believe that THS is harmful to children.” (Rehan, Sakurai, & Torday, 2011, p. L5) Temple and Johnson (2011) state, “…thousands of children continue to be exposed to ETS in our homes on a daily basis.” (Temple & Johnson, 2011). Home exposure also includes vehicles and homes of caregivers and relatives. The connection between third-hand smoke and health issues in children is arguably tenuous; however there is sufficient evidence to justify additional research in this area of environmental health.

Environmental Tobacco Smoke
Environmental tobacco smoke (ETS) may be defined as “…a combination of diluted sidestream smoke and mainstream smoke.”(Martin, 2009). As stated above side-stream smoke refers to the smoke coming off the cigarette as the tobacco burns and mainstream smoke is the smoke inhaled and then exhaled by the smoker. The distinction is important because the sidestream smoke has higher concentrations of carcinogens and toxins than mainstream smoke. Mainstream smoke is more often than not filtered plus a significant portion of the carcinogens are deposited in the lungs of the smoker and not exhaled. The particles in sidestream smoke are also smaller than those in mainstream smoke allowing greater entrance into the body, particularly through the respiratory tract (American Cancer Society, 2011). Rehan, Skurai and Torday (2011) in comparing toxicities of the various types of smoke found thirdhand smoke (THS):
…even more toxic in pragmatic terms and extent for potential human exposure. Because THS is essentially aged SHS that is adherent to surfaces and has smaller sized ultrafine particles but much larger size molecular weight moieties with greatly heightened asthma hazard index values, is likely to be much more toxic than MSS (mainstream smoke) and fresh SHS (Rehan et al., 2011, p. L6).

Rehan, et al, go on to say that exposure is most likely through dermal contact with contaminated surfaces and ingestion of dust containing THS contaminants (p. L6). This places children and pregnant mothers particularly susceptible to THS exposure due to activities that place them near contaminated surfaces and activities that stirs dust into the air to be inhaled. Rehan, et al. state the need for additional research in this area however they conclude that there is clear evidence that THS contains toxic substances that can have significant effect on the lung development and health of children born to a mother exposed to THS. (p. L7). Temple and Johnson (2011) “…linked ETS to an increased incidence of sudden infant death syndrome, respiratory disease, middle air infections, asthma, infections, and abnormal neurodevelopment.”(Temple & Johnson, 2011, p. 1). Studies cited in Warren, et al, (2010) indicate exposure to SHS is associated with certain intellectual deficits and asthma (Warren, Sloan, Allen, & Okuyemi, 2010). They go on to state, “In inner-city Minneapolis, Minnesota, nearly one in five households reported children aged less than six years are exposed to SHS and there is also a high concentration of children with asthma in this community.” (p. S44). The American Academy of Pediatrics on their Healthy Children website states,
If you smoke or are exposed to secondhand smoke when you’re pregnant, your baby is exposed to harmful chemicals to. This may lead to many serious health problems, including miscarriage, premature birth, lower birth weight than expected, sudden infant death syndrome, and learning problems and attention deficit hyperactivity disorder. (The American Academy of Pediatrics, 2010)

Secondhand smoke is classified as a “known human carcinogen” by the US Environmental Protection Agency (EPA) and other agencies including the World Health Organization (Environmental Protection Agency, 1992). Sleiman, et al, (2010) described their study which showed that residual nicotine from tobacco smoke reacted with ambient substances to form a tobacco specific carcinogenic agent. This carcinogenic agent’s presence on indoor surfaces such as clothing human skin etc. “…represents an unappreciated health hazard due to properties that allow it to be absorbed through the dermis, dust inhalation, and ingestion.” (Sleiman et al., 2010, p. 6576).
The chemicals in cigarettes include carcinogens such as tobacco specific-nitrosamines (TSNA), benzene, pesticides and formaldehyde. In addition they contain toxic metals such as arsenic and poisons such as ammonia, carbon dioxide, hydrogen cyanide, and nicotine. Secondhand smoke is known to contain at least 250 toxic chemicals in which at least 50 are carcinogenic. (Martin, 2011)
Unquestionably cigarette smoke contains toxic chemicals that are hazardous to both the smoker and non-smoker. In addition, the residue left behind on surfaces after the visual secondhand smoke has cleared is as toxic or more toxic than the original smoke. Another significant factor in the hazards of thirdhand smoke is its persistence in the environment. In studies cited by Burton (2011), nicotine coatings were found present in homes even where the residents try to limit smoking and even in vehicles where the primary driver was a non-smoker. Vehicles of eight smokers who imposed a smoking ban for the previous 12 months were tested and found nicotine contamination in dust and on the dashboard (Burton, 2011).

Exposure Scenarios
To illustrate the unintentional risk of exposure, I present the following scenarios that are not uncommon in today’s society.
Scenario 1 – One Parent Smokes
Recognizing the risk to their small child, the parents have an agreement that there will be no smoking in the house. The smoking parent must step outside to smoke when at home but does smoke in the car when alone. He also smokes at work, also outside. This arrangement is better than nothing however with what we know about thirdhand smoke, we know that the smoke residue is on the smoking parents clothes, on the seat covers and surfaces of the family car, and in his hair and on his skin. Therefore we know that the child is exposed to thirdhand smoke whenever dad picks him up or takes them in the car. Temple and Johnson (2011) report that when there is one person in the home smokes only 17.3% of those interviewed could maintain a smoke free home in only 10.8% could maintain a smoke-free vehicle(Temple & Johnson, 2011, p. 7). Herbert, Gagnon, Rennick & O’Loughlin (2011) state that a major barrier may be the habits and routines of partners and relatives. They quote a 42-year-old married mother of seven who stated that that her husband makes the intellectual connection however he habitually smokes when driving. On longer trips he claims it keeps him awake. (Herbert, Gagnon, Rennick, & O’Loughlin, 2011, p. 26)
Scenario 2 – Day Caregiver Smokes
Since both non-smoking parents work they have arranged inexpensive day care with the neighbor. Both the neighbor and her husband smoke however they have agreed not to smoke when the child is in the house. Again we have the same issue with residue on the caregivers close and in their hair and residue in the carpet, furniture and drapes in the care-givers home. The child experiences significant exposure estimated to be eight hours a day five days a week to the toxins and carcinogens in thirdhand smoke. Herbert, Gagnon, Rennick & O’Loughlin (2011) report that,
Most people are aware of the adverse effects of secondhand smoke exposure and are supportive of restrictions in public places, yet many are reluctant to restrict smoking in their own homes. This relates to the belief that smoking is an individual choice in the home environment, as well as a fear of offending family and friends. (Herbert et al., 2011, p. 23)

Scenario 3 – Pediatric Nurse is a Smoker
It is not uncommon for nurses and respiratory therapist to smoke, although this seems counterintuitive considering what they see on a day-to-day basis and their knowledge base. Hospitals have not allowed smoking in the US inside the facility for the past 30 years. However some hospitals still allow smoking on the property in designated smoking areas. Nurses and other caregivers who smoke take their breaks and go outside and smoke. If these caregivers are assigned to pediatric patients they then bring that thirdhand smoke back into the bedside on their clothes, in their hair and on their skin, thus exposing their patient to the toxins and carcinogens in that smoke residue. I have actually counseled nurses on this very topic and they more often than not believe that if they can’t smell it that it doesn’t exist. Hence they often come back into work smelling of freshly applied cologne. This does nothing but mask the smell; it does not mitigate the harmful effects of the thirdhand smoke residue.
Another little explored source of exposure to secondhand smoke is contamination of tobacco smoke from attached housing or apartments. Warren, et al (2010) identified high levels of cotinine in children living in attached housing with no smoking in their living area. Cotinine is a metabolite of nicotine and is used as a biomarker of exposure to nicotine. Fourteen percent of the children tested that lived in detached housing had a high level of cotinine compared to 64% of those living in the attached housing. There was also a similar relationship between children under the poverty level versus above the poverty level which would be consistent with the ratio of those living in attached housing versus detached housing (Warren et al., 2010, p. S46).

Summary
According to the Surgeon General’s report (2006), 126 million people are involuntarily exposed to secondhand smoke and 50,000 year die from secondhand smoke. His report concluded that there is no “safe” exposure to secondhand smoke (Office of the Surgeon General, 2006). However, homes still remains a source of significant exposure for children in non-smoking adults to toxic and carcinogenic residue from secondhand smoke. There is sufficient research to draw a straight line between smoking in the home and high levels of residual toxins. According to Winickoff et al (2009), “These toxins take the form of particulate matter deposited in a layer onto every service within the home; in loose household dust; and as volatile toxic campgrounds that “off gas” into the air over days, weeks, and months (Winickoff et al., 2009, p. e75). Children particularly toddlers have a greater exposure to thirdhand smoke because of their tendency to crawl on the floor and play on furniture. In addition, while crawling and playing they are breathing in the contaminated particles and one of the more common traits of all children is hand to mouth contamination. Winickoff et al state that infants ingest up to 0.25 g per day of dust that is twice that of the ingestion rate of adults (p. e78). In addition, he reports that similar to low levels of land, low levels of tobacco smoke markers are associated with cognitive deficits in children – “The highest tobacco exposure levels were associated with the lowest reading scores; however levels of exposure were associated with the steepest slope in the decrement in reading levels.” (p. e78). This indicates that even at the lowest levels, exposure to tobacco smoke whether secondhand or thirdhand is neurotoxic. Therefore a strict ban on smoking in all areas visited by children is the prudent choice.
There is sufficient evidence to support a conclusion that thirdhand smoke is hazardous to all, particularly children. It is critical that health messages about the hazards associated with secondhand and thirdhand smoke to parents whether from a healthcare provider, government agencies, or families and friends are communicated loud and clear. In addition well-designed research into several areas is indicated. First is additional research to confirm limited research that is already been conducted. One or two studies are not enough to unequivocally establish hazards associated with thirdhand smoke. The results of the existing studies and any future studies need to be communicated to smokers in a manner they will understand. As an adult they might take the risk associated with being a smoker, however protecting their children might be the final straw in convincing them to quit or limit their smoking. The third area that requires additional research is techniques and procedures to mitigate the risk in the already contaminated household.
Additional research might hold the answer to unexplained conditions such as autism, attention deficit hyperactivity disorder, and other childhood syndromes that cannot be attached to a more specific causative factor.

Nursing workload is usually considered to be the number of patients each nurse has assigned to them for the shift. Although nurse patient ratio and the numbers and types of nurses assigned to a unit play an essential part of how workload is measured, it is only a small part of the picture. Turbulence plays a significant role, as do other factors such as collateral duties , and unassigned or unforeseen situations. The turbulence inherent in our modern healthcare facilities disrupts the smooth workflow of day-to-day operations and in particular bedside nursing. Jennings (2008) has described this as “staff nurses are striving to meet complex patient needs that require rapid decision making, despite there being fewer resources and more interruptions and distractions” (p2-193 ). Collateral duties are those that help maintain the nursing function of the unit and are assigned along with patient care duties. The unassigned or unforeseen situations account for what Carayon and Gurses (2008) have described as situational workload. The authors contend that this is the level that is often overlooked and grows insidiously over time. This is often placing the patient in a lower position of priority in order for the nurse to accomplish all that is demanded. It is how, unintentionally, we are spurring the growth of nursing with a task orientation versus that of a professional, patient-centered orientation.

To control nursing workload along with maintaining fiscal responsibility, hospitals have relied on average daily census and patient acuity to quantify the hours of care each patient needs a day. The financial viability of healthcare facilities requires optimal staffing levels that recognize the unique work environment of nurses. This is no simple task. Nursing care hours cannot be quantified in a vacuum due to the symbiotic relationship between nursing and other ancillary and support departments.

Situational level workload is best described as the workload perceived by the nurse due to the design of the healthcare microsystem. Scrutinizing situational workload of nurses reveals a complex environment. Nurses may have to work on units that are poorly designed for today’s demands: long hallways, multiple beds in some patient rooms, poorly located equipment storage, poor lighting and noise control are a few examples. It also encompasses factors such as miscommunications between the healthcare team that take the nurse’s time and efforts to clarify, patient turnover, negotiating complex and changing facility policies, complex patient and family issues, and time pressures (Carayon and Gurses, 2008).

Adding to the mix, many of the collateral duties assigned to nurses such as emptying trash, delivering trays, order entry, reconciliation of daily charges, extra demands from medical staff, students, surveillance for other departments, ordering and stocking supplies and follow up on non-delivered items or scheduled events take the nurse’s time and add considerably to the workload. Turbulence in the workday is often the rule not the exception.

Examining levels of workload more closely, it can be discerned that unit, patient numbers, acuity, and job levels cannot always determine the true workload nurses face. For example, using the patient level to determine workload discounts the effects of factors such as information technology issues, communication issues, and other departmental issues such as scheduling and nurses Some acuity systems attempt to address this by giving a small amount of credit to non-nursing duties; however, they may not accurately capture the culture or the cyclical nature of turbulence of the unit. Unit level assumes the most important contribution to workload is the nurse-patient ratio. By using this measure, unit and patient outcomes can be compared and staffing can be linked to poor or optimal outcomes. (Carayon and Gurses, 2008). This is demonstrated in Aiken’s (2002) article, cited on numerous occasions, relating staffing to mortality in hospitalized surgical patients and the paper regarding mandated ratios utilized in California. Less patient mortality resulted but the unforeseen consequence of loss of assistive personnel was also a result (Aiken, 2010). Looking at this level of workload to solve nursing workload problems can be misleading as it usually ignores the context of organizational characteristics and situational issues. Finally, job level fails to account for the numerous circumstances that nurses encounter on a daily basis while trying to care for their patients. The situational level of workload must therefore be addressed.

Situational workload accounts for part of what is described in the literature as environmental turbulence where practitioners sense a lack of control. Unfortunately, the nurse’s response to turbulence may be call offs, mental stacking with overload, and workarounds that often lead to poor patient outcomes and/or dissatisfaction (Jennings, ).

Solutions to nursing workload issues are as complex as the issues themselves. Looking to nursing’s foundations may hold the key to the answers. The Code of Ethics for Nurses (The Code) lays the groundwork as it clearly states the nurse’s duty to the patient, healthcare environment, and self. Specifically, provision two states that “the nurse’s primary duty is to the patient….(ANA, 2010 p. 11)”, not collateral duties. In provision six the nurse’s responsibility to “participate in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare…(ANA, 2010 p. 71)” is discussed focusing on nursing having a duty to assure the virtues and values central to our profession are maintained. As professional nurses we need to ask ourselves ‘when did doing things other than direct and indirect patient care become a priority over the patient’? Finally, The Code reminds nurses through provision five “the nurse owes the same duties to self as to others…(ANA, 2010 p.55)”. We are a respected profession, each one of us is important to each other and those we serve. We deserve to be treated with respect and our input valued. Our input into staffing committees is vital for success of the profession.

In the state of Nevada, staffing committees were legislated in 2009 and revised legislation proposed in 2013. These committees must have bedside nurses as part of their membership and be used by facilities to determine adequate staffing . The committees need to examine the situational workload and not simply the unit’s average daily census and acuity level. In all cases, nursing needs to make changes within their control. For example, collateral duties need to be studied and common sense as well as financially sound alternatives should be evaluated. This may encompass other departments examining their duties to bring them in alignment with their departmental function. Cost containment in one department may inadvertently add to nursing’s burden with the unintended consequences of distracting the nurse from their primary duty to the patient, poor outcomes, and nurse burnout. Unfortunately, nursing can take on duties not regulated by law but it does not work in reverse that non-nurses can perform professional nursing duties. Nursing leaders need to remain vigilant in the prevention of duty creep so that the patient remains the focus for nursing staff and that situational workload does not end in nurse burnout. They need to listen to their staff and protect them from small non-nursing duties that add up and take their toll on workload. Nursing needs to be able to focus on caring for patients to maintain patient safety and quality outcomes.

The authors contend that this is the level that is often overlooked and grows insidiously over time. This is often placing the patient in a lower position of priority in order for the nurse to accomplish all that is demanded. It is how, unintentionally, we are spurring the growth of nursing with a task orientation versus that of a professional, patient-centered orientation.

These duties could and should be performed by people other than nurses (Carayon and Gurses, 2008). Proximity to the situation should not mean that the task automatically belongs to nursing!